Rotator Cuff Tears: Evidence Based Practice

The rotator cuff is a group of four muscles and their tendons that form a supportive "cuff" around the shoulder joint. These muscles – supraspinatus, infraspinatus, teres minor, and subscapularis – play a vital role in keeping the shoulder stable while allowing us to lift, rotate, and raise the arm. Whether it's reaching overhead, carrying groceries, or playing sports, the rotator cuff is constantly at work.

What Causes Rotator Cuff Tears?

Rotator cuff tears may occur due to different reasons:

1. Acute injuries – A sudden fall, lifting a heavy object, or a traumatic event.
2. Repetitive strain – Repeated overhead use (common in athletes and manual workers) can wear down the tendons over time.
3. Age-related changes – As we get older, tendons naturally lose elasticity and strength, making them more prone to injury.

Aging and Rotator Cuff Tears

As we age, the rotator cuff undergoes several changes – reduced blood supply, muscle loss, tendon degeneration, and changes in bone structure. This makes tears more likely, even without a major injury. Interestingly, many tears are asymptomatic and may go unnoticed.

Symptoms

Rotator cuff tears can range from small, partial injuries to complete ruptures. The size of the tear does not always match the severity of symptoms. Common signs include:

• A dull ache in the shoulder or upper arm
• Weakness in the affected arm
• Difficulty lifting the arm overhead
• Pain at night, especially when lying on the affected side

Do You Need a Scan?

Not every shoulder pain needs imaging. In many cases, your history and physical examination give enough information for a diagnosis. However, imaging may be recommended if the diagnosis is unclear or surgery is being considered:

• X-ray – Useful after trauma to rule out fractures but does not show tendons.
• MRI – The gold standard for detecting tears, showing detailed images of muscles, tendons, and joint structures.
• Ultrasound – A cost-effective, dynamic option, though less reliable than MRI for small or complex tears.

Treatment Options

The right treatment depends on your age, activity level, type of tear, and goals. Fortunately, many people improve with conservative (non-surgical) management, especially in degenerative tears.

Conservative Management

1. Physiotherapy – The first line of treatment. Focuses on restoring strength, range of motion, and function through tailored exercises.
2. Manual therapy – Helps relieve associated stiffness and night pain in the neck and shoulder.
3. Activity modification – Avoiding movements that worsen symptoms.
4. Medications – NSAIDs may help reduce pain and inflammation, though in acute injuries, their use is often delayed to support natural healing.

When to Consider Surgery

Surgical opinion is usually considered if:

• Symptoms persist despite consistent conservative treatment
• You are under 60 years of age
• The tear is linked to a traumatic incident
• Multiple tendons are involved (though not always necessary)
• You have high functional demands such as overhead sports or physical work

Key Takeaway

Rotator cuff tears are common, especially as we age, but they don't always require surgery. With the right physiotherapy program and activity modifications, many people regain strength, reduce pain, and return to their daily activities without invasive treatment.